The Injury

General Considerations:

Mid-shaft clavicle fractures occur most commonly from falls onto the shoulder.  We see the most from bicycling, skiing and snowboarding falls.  Clavicle fractures present a unique challenge to self-healing because the shoulder cannot be placed in a cast during the healing process. The clavicle is directly under the skin with no overlying fat, making fractures cosmetically apparent, and moreover, they hurt.  

Surgical fixation of the clavicle is being recommended more frequently in order to promote healing. Recent studies indicate long-term shoulder weakness and mal-union from fractures with an overlap or a distraction of more than 1 centimeter when left untreated.  A new intramedullary fixation technique has permitted normal alignment and restoration of length of the clavicle with an early return to work and sports. The risks of surgery, including non-union and infection, are still present; however, for athletes who want to return to full sports as early as possible, and for people who are concerned about optimal anatomic alignment and healing, this technique has served these patients well. The indications, surgical technique and rehabilitation program is described here.

Surgical treatment - Indications:

• Mid-shaft clavicle fractures with overlap or displacement greater than 1 centimeter.
• Tenting of skin by fracture fragments
• Active patient with desire for early return to work and healing with no loss of length or strength.

Surgical  treatment - Contraindications:

• Skin wounds at the incision site.
• Inability to follow the rehabilitation program.

Surgical treatment - Pro's:

Surgical intervention can allow the patient to:

• regain length.
• regain stability.
• return to work.

Furthermore, surgical fixation will promote proper healing by preventing:

• overlap between the fractured bone.
• development of a fibrous non-union.

Surgical treatment - Con's:

• Higher infection rate estimated at less than 1%.
• Potential hardware complications or failure.
• Skin incisions.
• Non-union risk.
• Surgical regional block risks.

Surgical Technique

The patient is seated in the beach-chair position after an interscalene local anesthetic block is placed. The fracture ends are opened with a scalpel and cleaned.  A guide pin is passed into the medial portion of the clavicle under fluoroscopic x-ray control and over-drilled to fit a 6.5 mm or 4.5 mm screw.  The guide pin is then removed and passed into the lateral clavicle fragment and similarly over-drilled.  The pin is directed out the back of the clavicle.  The drill is attached to the exiting end and redirected to pin the full length of the clavicle under x-ray control.  Finally, a cannulated screw and washer is passed from the back down the bore of the clavicle to fix the fracture.  Care is taken to engage, but to not penetrate, the medial end of the cortex of the bone.  The incision is then closed.

The following is an x-ray image of a mid-shaft clavicle fracture:

(Rollover the image to highlight the injury.)

X-rays demonstrating this reduction of the fractured mid-shaft clavicle in a professional Race Across America cyclist, who cycled within one month of his injury:

(Rollover the image to highlight the injury repair.)

Post -Operative Rehabilitation

General Considerations:

• DO NOT elevate surgical arm above 70 degrees in any plane for the first 4 weeks post-op.
• DO NOT lift any objects over 5 pounds with the surgical arm for the first 6 weeks.
• AVOID REPEATED reaching for the first 6 weeks.
• Ice shoulder 3-5 times (15 minutes each time) per day to control swelling and inflammation.               
• An arm sling is used for 3- 4 weeks post-op.
• Maintain good upright shoulder girdle posture at all times and especially during sling use.
• Intermittent X-ray to monitor healing as needed
• M.D. follow-up visits at Day 1, Day 8-10, Month 1, Month 3 and Year 1 post-op.

Week 1:

• M.D. visit day 1 post-op to change dressing and review home program.
• Exercises (3x per day):
  • pendulum exercises
  • squeeze ball
  • triceps with Theraband
  • isometric rotator cuff external and internal rotations with arm at side
  • isometric shoulder abduction, adduction, extension and flexion with arm at side.
• Soft-tissue treatments for associated shoulder and neck musculature for comfort.
• Cardiovascular training such as stationary bike throughout rehabilitation period.

Weeks 2 - 4:

• Soft-tissue treatments for associated shoulder and neck musculature for comfort.
• Gentle pulley for shoulder ROM 2x/day.
• Elbow pivots PNF, wrist PNF.
• Isometric scapular PNF, mid-range.

Weeks 4 - 8:

• M.D. visit at Week 4 post-op and will usually be progressed to a more aggressive ROM and strength program.
• At Week 4: start mid-range of motion (ROM) rotator cuff external and internal rotations active and light resistance exercises (through 75% of ROM as patient's symptoms permit) without shoulder elevation and avoiding extreme end ROM.
• Strive for progressive gains to active 90 degrees of shoulder flexion and abduction.

Weeks 8 - 12:

• Seek full shoulder Active ROM in all planes.
• Increase manual mobilizations of soft tissue as well as glenohumeral and scapulothoracic joints for ROM.
• No repeated heavy resisted exercises or lifting until 3 months.

Weeks 12 and beyond:

• Start a more aggressive strengthening program as tolerated.
• Increase the intensity of strength and functional training for gradual return to activities and sports.
• Return to specific sports is determined by the physical therapist through functional testing specific to the injury.